Krazy Kodachromes Series
updated regularly - Approach image questions on exams and practice with hours of discourse and differentials with GW School of Medicine faculty.
Watch the video at DermInReview.com.
Volume 6 | Issue 5
Robert M. Hurwitz MD, Larry J. Buckel MD, Thomas J. Eads MD
A new classification of melanocytic nevi is presented that may incorporate 1 of 3 anatomic patterns, 1 of 12 architectural
patterns, and 1 of 3 cellular patterns in the diagnosis. In this scheme, the patterns are easy to understand, logical,
and the end result is an unambiguous descriptive diagnosis. A pattern diagnosis for melanocytic nevi allows for an understandable
and reproducible interpretation by the physician. The nosology of a pattern diagnosis is familiar to physicians.
It is common to have a variety of histopathologic patterns for a clinical condition alone or in combination and to
be portrayed in the clinical diagnosis. There are countless examples in the literature, such as squamous cell carcinoma
(superficial, spindle cell, atypical fibroxanthomatous, pseudovascular types) and basal cell carcinoma (superficial, nodular,
pigmented, cystic, morpheaform, fibroepithelial types) to mention but a few. Our classification emphasizes the benignancy
of the melanocytic nevus and makes it feasible for the physician to picture it. A pattern diagnosis thus results
in a bona fide service to the patient resulting in less confusion, misinterpretation, or fear of malignancy, as well as unnecessary
Debra Breneman MD, Pranav Sheth MD, Vivian Berger LPN, Vahid Naini PharmD, Victor Stevens PhD
We report the results of a nonrandomized, open-label pilot trial investigating the safety, tolerability, and efficacy of
bexarotene gel 1% in treating chronic mild to moderate plaque psoriasis.
Twenty-four adults with mild to moderate stable plaque psoriasis involving 15% or less of their body surface were enrolled.
Patients applied bexarotene gel 1%, using an application frequency escalation regimen, starting at once every other day
and increasing to 4 times daily as tolerated and beneficial for up to 24 weeks.
The primary efficacy instrument was a Physician’s Global Assessment (PGA) score evaluating the overall response to treatment.
This utilized individual signs of psoriasis and the percent of body surface area involvement. Safety assessments included
physical examinations, recording of adverse events, and laboratory safety evaluations.
Fifteen out of 24 enrolled patients (63%) achieved at least 50% improvement by PGA score at 2 or more consecutive
visits, and 6 (24%) achieved clearing of 90% or more. Six patients maintained a response throughout 8 weeks of followup.
An increased response appeared to correlate with a higher frequency of gel application. Adverse events occurred primarily
at application sites and were mild or moderate in severity.
Bexarotene gel 1% was active in treating mild to moderate plaque psoriasis with achievement of durable responses in some
patients and was well-tolerated. A randomized, placebo-controlled study would be useful in confirming these results.
Claudia Schiessl MD, Carola Wolber MD, Martina Tauber MD, Felix Offner MD, Robert Strohal MD
Forty-one patients with 47 basal cell carcinomas (BCCs; 15 superficial, 26 nodular, and 6 sclerodermiform) were treated
with 5% imiquimod cream once daily 5 times a week for 6 weeks in an open-label clinical trial. The overall response rate
was 95.7%. Local side effects occurred in 68% of the patients as mild to moderate reactions with a clear association to
the histological BCC subtype. Follow-up examinations for up to 17 months (median 10 months) showed scars in 14.9%
of the patients and a recurrence rate of 6.6%. Overall, imiquimod represents a safe and effective treatment option for a
selected cohort of BCC patients. Notably, by the second week of treatment 72.7% of BCC biopsies were histologically
tumor-free, which correlated with a substantial decrease of the inflammatory infiltrate by up to 58% between weeks 3 to
6. This early imiquimod response might have important implications for the final definition of potentially shorter imiquimod
Flor A. Mayoral MD, Janelle M. Vega MD, Henry Stavisky PhD, Calogera L. McCormick BA, Anne Parneix-Spake MD
Objective: To explore the effectiveness of pimecrolimus cream 1% used twice daily (BID) for the treatment of facial vitiligo.
Methods: Patients who had used pimecrolimus cream 1% monotherapy BID for at least 3 months and who had photographs
taken at baseline and after initiation of therapy were analyzed in a retrospective study. The total affected surface
area (cm2) of facial vitiligo in the baseline and follow-up photographs was compared. The extent of facial depigmentation
was scored using a 7-point scale (0=no disease to 6=100% involvement).
Results: Eight patients met study entry criteria. Mean time from initiation of treatment to the final follow-up visit was
11 months (SD±7.5 months). Mean affected surface area at baseline and follow-up were 79.40 cm2 and 17.96 cm2, respectively,
(P=.012) with a mean percent improvement 72.5% (SD±20.4%). Mean depigmentation score decreased from
2.8 at baseline to 1.4 at follow-up. No adverse events were reported.
Conclusion: Pimecrolimus cream 1% may be a viable alternative to current therapies for the treatment of facial vitiligo.
Lawrence F. Eichenfield MD, Melissa L. Bogen ELS
Background: The potential for toxicity from systemic absorption of topical miconazole in infants is a concern.
Objective: To assess the relative safety of 0.25% miconazole based on the amount absorbed through the skin of infants
with diaper dermatitis after multiple applications.
Methods: Of 24 infants with moderate to severe diaper dermatitis, 19 received 0.25% miconazole nitrate ointment and
5 received 2% miconazole nitrate cream for 7 days at each diaper change and after bathing. Blood samples were collected
prior to treatment and after 7 days.
Results: In the 0.25% treatment group, blood concentrations of miconazole were nondetectable (<1 ng/mL) in 83%
(15/18) and minimal (3.0 to 3.8 ng/mL) in 17% (3/18). Samples were missing for one patient. For the 5 infants in the
2% treatment group, miconazole concentration was nondetectable in 20% (1/5) and less than 7.4 ng/mL in 4 infants.
No adverse events were noted.
Conclusions: Systemic absorption of 0.25% miconazole nitrate ointment was minimal, demonstrating its safety in the treatment
of moderate to severe diaper dermatitis.
Jennifer F. Conde BA, Christopher B. Yelverton MD MBA, Rajesh Balkrishnan PhD, Alan B. Fleischer Jr. MD, Steven R. Feldman MD PhD
Background: Rosacea is an extremely common chronic dermatosis affecting an estimated 14 million Americans. Rosacea
is most commonly managed with topical metronidazole, sometimes in combination with oral antibiotics.
Purpose: To review published studies about topical metronidazole therapy for rosacea, both as a monotherapy and in conjunction
with oral antibiotics.
Methods: Medline searches were conducted for clinical trials using metronidazole, tetracycline, and doxycycline for rosacea.
Results: Topical metronidazole has been well studied as a rosacea therapy. Twice-daily dosing of metronidazole 1.0% cream
is as effective as 250 mg tetracycline twice daily. Metronidazole 1.0% gel used once daily is as effective as azelaic acid 15%
gel dosed twice daily. When dosed at subantimicrobial levels, doxycycline 20 mg taken twice daily is effective in decreasing
inflammatory lesions and erythema associated with rosacea. Metronidazole 0.75% lotion is more effective when used in
combination with doxycycline 20 mg dosed twice daily.
Discussion: Metronidazole in 0.75% strength lotion, cream, and gel and 1.0% metronidazole cream and gel are all efficacious
in treating rosacea. Combination treatment with oral antibiotics at both antimicrobial and subantimicrobial doses
is an efficacious means of treating rosacea. Maintenance treatment with topical metronidazole decreases relapses and allows
for longer intervals between flares.
Brittney L. Culp MS, Michael J. Wells MD
Generalized urticaria is an adverse and serious side effect of diphencyprone. We report a case in order to advise of the possibility
of associated type I hypersensitivity reaction (urticaria), which could progress to a more severe or life-threatening
Maria Rita Nasca MD PhD, Rocco De Pasquale MD, Giuseppe Micali MD
We report a case of a 43-year-old uncircumcised Caucasian, diabetic man with a 4-year history of Zoon’s balanitis unresponsive
to topical steroids, in whom control of the disease was achieved with topical imiquimod. A histopathological examination
of a biopsy specimen was performed before and after treatment with imiquimod 5% cream applied 3 times a
week. A moderate to marked increased local skin reaction occurred several times throughout the treatment period, necessitating
multiple rest periods of several days’ duration. Clinical but not histological resolution was obtained after 4 months
of treatment, with no relapses at an 18-month follow-up. This positive treatment outcome indicates that imiquimod may
have a role in the management of Zoon’s balanitis. However, the dose and duration of therapy required to achieve complete
clinical response still needs to be established. Also, the question of whether normalization of histology can be achieved
with topical imiquimod has yet to be answered.
Bengu Nisa Akay MD, Ahu Arslan MD, Saban Cekirge BS, Gul Erkin MD, Rana Anadolu-Brasie MD
Lichen planus (LP) is an idiopathic, inflammatory, pruritic dermatosis of unknown origin. An increased prevalence of a
wide range of diseases such as viral hepatitis C, hepatitis B, primary sclerosing cholangitis, and primary biliary cirrhosis
have been associated with LP. Recently, LP has been reported following administration of different types of hepatis B vaccines
but a relationship with an inactivated influenza vaccine (Fluarix®, GlaxoSmithKline) has not been reported previously.
We present a case of generalized LP manifesting 7 days after the first 0.5-ml dose of influenza vaccine, administered
via deltoid injection. LP is possibly a viral antigen-triggered inflammatory skin condition, the pathogenesis of which needs
to be further explored.
Hani A. Al-Shobaili MD, Khalid M. AlGhamdi MD, Walid A. Al-Ghamdi MD FRCPC
Sebaceous carcinoma (SC) is a rare and aggressive cutaneous neoplasm. It may arise in ocular or extraocular sites. Approximately
25% of all reported cases of SC are extraocular. Cystic presentation of sebaceous neoplasm is rare. So far, cystic
sebaceous neoplasia (CSN) has been reported only in association with Muir-Torre syndrome (MTS). Furthermore, CSN
has recently been characterized as a marker lesion of MTS. We report a case of CSN of the nose that was not associated
with MTS. Mohs micrographic surgery was performed with no recurrence for 2 years. Patients with MTS need long-term
follow-up to detect possible future presentation of MTS.
Christopher M. Wolfe PA-C, Armand B. Cognetta Jr. MD
Background: Actinic keratoses (AKs) are a common premalignant tumor of the skin. Several treatment modalities exist
for broad-area therapy. Photodynamic therapy (PDT) is one such treatment modality. Disruption of squamous epithelium
locally compromises the normal physical barrier of the skin, potentially allowing bacteria penetration into the dermis. This
may occur subsequent to PDT, resulting in cellulitis and its sequelae. Undiagnosed and untreated this can prolong recovery
times and increase patient discomfort.
Objective:We report 4 cases of cellulitis that developed after treatment of AKs with PDT. These cases developed 1 to 4
days after PDT.
Methods: Standard short-contact 2-hour incubation is performed on patients receiving treatment on the face or scalp. Patients
are contacted by telephone on day 1 and day 3 postprocedure. Patients are asked to call immediately if they experience
no resolution of discomfort or an abrupt increase in pain in the days following treatment. Those patients reporting
an increase in pain and discomfort on either of these days are asked to come to the office for examination. A culture and
sensitivity is performed on those presenting with cellulitis clinically and empiric antibiotic therapy is initiated. Antibiotic
therapy is adjusted, if necessary, based on the culture and sensitivity report.
Results: All cases of cellulitis presented with an increase in pain and burning as the primary symptom between day 1 and 4
following PDT. The appearance of impetiginized areas or pustules was clearly evident in 2 out of the 4 patients. A culture
and sensitivity confirmed the growth of staphylococcus aureus in all 4 patients.
Conclusion: Cellulitis should be considered as a possible complication in patients reporting an abrupt increase in pain or
those who do not experience a gradual resolution of pain and discomfort following PDT.
Kenneth Beer MD, Jeanine Downie MD
We report a case of a 53-year-old African American woman with an unusual example of striae caused by topical steroid
usage and discuss the widespread usage of these products.
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